Basic Information
| Provider Information | |||||||||
| NPI: | 1821086000 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PALMER | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | ANTHONY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 705 S UNIVERSITY AVE | ||||||||
| Address2: | STE 350 | ||||||||
| City: | BEAVER DAM | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539163053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9208870379 | ||||||||
| FaxNumber: | 9208870382 | ||||||||
| Practice Location | |||||||||
| Address1: | 705 S UNIVERSITY AVE | ||||||||
| Address2: | STE 350 | ||||||||
| City: | BEAVER DAM | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539163053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9208870379 | ||||||||
| FaxNumber: | 9208870382 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2005 | ||||||||
| LastUpdateDate: | 11/01/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 44261020 | WI | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 34216200 | 05 | WI | MEDICAID |